AIP Intake Assessment

Have you been previously involved with an AIP or Anger Management Program?

Yes

Please Describe why you have been referred to AIP at Iris Family Support

Criminal & Legal History Assessment

Is there a protective order in place?

Yes

Have police been called to your house due to a violent incident?

Yes

Have you been arrested for a violent crime?

Yes

Is there a NCO in place?

Yes

Did you serve any jail/prison time?

Yes

Have you ever been to counseling for abusive behavior?

Yes

Are you currently on probation or parole?

Yes

Domestic Violence Assessment

When you were growing up, did you hear or witness violence at home, school, or in your community?

Yes

When you were growing up, did you use violence against friends, family, or others?

Yes

Have you been in more than one relationship involving domestic violence?

Yes

Do you consider yourself a violent person?

Yes

What might happen if you do not stop using violence against others?

When you were an adolescent, did you witness any violence in your home?

Yes

If yes, please explain.

Relationship History Assessment

The following are some behaviors that many people admit to using or to being victim of in their relationships. Please mark all of the behavior's you have used in your relationships.

Have you used any of the following physical behaviors?

Have you used any of the following intimidating behaviors?

Frightened your partner by giving them certain looks, gestures, or actions

Screamed at them

Have they ever said that they are afraid of you (emotionally/financially/physically/sexually)

Followed/Stalked them

None of these

Have you ever used any of the following emotionally abusive behaviors?

Made them feel bad about themselves

Humiliate them

Made them feel guilty

Called them names

Accused them of flirting and/or cheating

None of these

Have you used any of the following minimizing, denying, or blaming behaviors?

Make jokes about the abuse/violence

Blamed your partner and said it was their fault it happened

Said that the abuse/violence did not happen

Blamed it on someone/somthing else

None of these

Have you ever used any of the following isolating behaviors?

Kept your partner from going places

Opened their mail/did not give them their mail

Told them they could not speak to certain people

Listened to phone calls/read texts or emails

None of these

Have you used any of the following behaviors involving your children?

Told the children that your partner is not a good parent

Used the children to deliver messages to your partner

Threatened to take away the children or keep them from seeing your partner

Used their parenting time to harass them

None of these

Have you used any of the following financially abusive behaviors?

Prevented them from working outside of the home

Told them that they cannot have a job at all

Withheld information about the family's income

Made major financial decisions without their input

Refused to pay child support

Made them ask for money

Demand that they pay all the bills

None of these

Have you ever used any of the following coercive or threatening behaviors?

Threatened to harm them

Threatened to harm yourself

Threatened to harm friends/family

Tried to get them to drop criminal charges/protective order

None of these

Have you ever used any of the following behaivors to exert power over your partner?

Acted like the head of the household

Told them what their role is in the relationship and/or family

Treated them like a servant

Bossed them around

Made household rules without them

None of these

Select Yes or No if any of the below experiences have occurred in your relationships.

Has your partner ever needed to get outside help because of the abuse/violence?

Yes

Have you ever pushed/hit/shoved your partner while she was pregnant?

Yes

Has your partner ever received medical treatment due to your violence?

Yes

Have you ever threatened to kill your partner?

Yes

Have you ever threatened or acted like you were going to use a gun or weapon towards your partner?

Yes

Have you ever injured or killed a pet/animal

Yes

Have you ever threatened or tried to kill yourself?

Yes

Have you ever pressued your partner to have sex with you?

Yes

In the past six (6) months has your relationship:

Stayed about the same with no new incidents of abuse/violence

Become more violent

Become less violent

Become "brand new", exciting, and healthy

Unsure/unable to label the relationship dynamic

Relationship has ended because of a No-Contact Order or Protection Order

Child Exposure Questionnaire

Mark yes, no, or unknown if any of the experiences below ever happened in front of or in the same home as your children

Have your children witnessed emotional abuse towards you/your partner?

Yes

Have your children witnessed physical abuse towards you/your partner?

Yes

Have your children witnessed sexual abuse towards you/your partner?

Yes

Have your children witnessed a pet/animal being injured/killed?

Yes

Have your chilren been asleep or in another room during abusive/violent incidents?

Yes

Have your children witnessed police/DCS coming into the home?

Yes

How did your children respond after witnessing the violence?

They tried to stop the violence

They copied the violence

They hid and/or ran away

They reported being sad or afraid

They called 911 or a family member for help

Their eating/sleeping habits changed

None of these

Alternatives to Violence

Try to remember how often you did the following things in your relationship. Rate the items below using the scale of often, sometimes, or never

Discussed issues relatively calmly

Often

Sometimes

Never

Asked for your partners opinion

Often

Sometimes

Never

Talked through a discussion

Often

Sometimes

Never

Supported their decision to do something for themselves

Often

Sometimes

Never

Listened to your partner

Often

Sometimes

Never

Apologized to your partner

Often

Sometimes

Never

Left the room to calm down when you felt yourself getting upset

Often

Sometimes

Never

Supported a decision your partner was making/had made that you did not agree with

Often

Sometimes

Never

AIP Intake Assessment

Please list your:

Please list your partner's:

Criminal & Legal History Assessment

Domestic Violence Assessment

Relationship History Assessment

Child Exposure Questionnaire

Alternatives to Violence